Archives 2015 vol *

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1 April 30, 2015 Archives 2015 vol PHARMACOTHERAPY EVALUATION OF DIABETIC PATIENTS IN WARD OF GENERAL MEDICINE, NORTHWEST GENERAL HOSPITAL & RESEARCH CENTRE, A CASE STUDY FROM KHYBER PAKHTUNKHWA, PAKISTAN. Ali, I. 1* ; Khan, J. Z. 2 ; Khan, A. U. 1 ; Ullah, I. 1 ; Ahmad, F. 2 1 Department of Pharmacy Services, Northwest General Hospital & Research Centre, Peshawar,Khyber Pakhtunkhwa, Pakistan 2 Department of Pharmacy, University of Peshawar, Peshawar, Khyber Pakhtunkhwa, Pakistan * iftikhar_rph@yahoo.com Abstract Drug therapy problems are frequent and major challenge to health care providers that are related with morbidity, mortality and patient s quality of life. This study aimed to identify drug related problems and to highlight the role of clinical pharmacist at ward level in tertiary hospitals of district Peshawar, Khyber Pakhtunkhwa Pakistan. A total of 15 diabetic patient s drug therapy details were recorded in medical Ward at Northwest General Hospital and Research Center, Peshawar, on a standard designed questionnaire which included patients demographics, disease history, medication history, laboratory data, diagnosis and drugtherapy provided in the hospital, monitoring notes and management plan for drug related problems, discharge medication, treatment outcomes and other pertinent information from December 2013 to February 2014.The percentage incidence of type II diabetes mellitus 13 (86.66%), gestational diabetes 1 (6.6667%), type I diabetes mellitus 1 (6.6667%) were documented.the total number of patients were 15, out of which 6 (40%) were male and 9 (60%) were female. A total of 33 DRPs were identified from 15 patients drug therapy details. Majority drug related problems resulted from drug-drug interactions (60.06%). In order to optimize pharmacotherapy and eliminate drug related problems, pharmacist should be placed in health care team in ward level. With the focus on individual patients, extensive and responsible clinical pharmacy services will be a crucial segment of modern-day health care. Key words: Drug related problems, Pharmacist, Diabetes Mellitus, Drug interactions Abbreviations: Drug related Problems (DRPs), Pharmaceutical care network Europe (PCNE)

2 PhOL Ali et al 105 ( ) Introduction Diabetes mellitus is a syndrome characterizes by diminished carbohydrates, fat, and protein metabolism brought on by either lack of insulin secretion or diminished sensitivity of the tissues to insulin [1]. Drug-related problems are pharmacotherapy problems that truly or potentially have an impact on desired health outcome [2]. This is probably due to patients receiving multiple drugs to control their medical conditions, all of which promote DRPs. Several factors could contribute to DRPs. In geriatrics, co-morbidities, poor medication adherence and poly-pharmacy potentially cause DRPs [3,4]. Drug related issues could be characterized as any occasion or condition including the drug therapy, which interferes on the other hand conceivably, interferes with the patient, attaining an ideal outcome of desired therapeutic goal. Drug related problems are frequent and may result in reduced quality of life, and even morbidity and mortality [5]. Drug therapy has become so difficult that no one professional is expected to optimize the drug therapy and control drug related problems alone. Drug-related morbidity and mortality are often preventable, and pharmaceutical services can reduce the number of ADRs, the length of hospital stays and the cost of care. Pharmacists must abandon factionalism and adopt patient-centered pharmaceutical care as their philosophy of practice [6]. The aim of the study was to identify the drug related problems and highlight the role of clinical pharmacist in a tertiary care setting. Material and method This study was carried during a 3-months period from 25 th November 2013 to 8 th February 2014 in Medical Ward of Northwest General Hospital and Research Center, Peshawar, Khyber Pakhtunkhwa, Pakistan, among patients who were being treated under the medicine ward, in-patients of both sex and age undergoing treatment for diabetes were included. A standard questionnaire was designed for recording patient s case histories and all other relevant information as described by Fazli Khudaa et al 2013[7]. We have applied the database to check drug-drug interactions using Micromedex Drug-Reax Software (Thomson Reuters Healthcare Inc., Greenwood Village, Colorado, United States and the drugs.com website as previously used by Stephany Duda in 2005[8]. The PCNE Classification V 6.2 were used for the documentation of DRPs throughout the study. All relevant DRPs were discussed within the healthcare team during ward rounds. The patient s response to drug treatment was monitored throughout the hospital stay. Data were analyzed in Microsoft Excel. Results A total of 15 patients drug therapy details were recorded in 3-months study period,among the 15 patients 6 (40%) were male and 9 (60%) were female, mean age was 54 years and average hospital stay was 7 days. The demographic details and comorbid conditions of patients are summarized in table 1. The main cause of hospitalization was diabetes mellitus, sign, symptoms and the co-morbid conditions are given below in figure 1. The nature of potential drug therapy problems, grouped to three, categories were identified namely, prescriber related potential DRPs, drug related potential DRPs and patient related DRPs. The whole medication therapy provided in the hospital was analyzed for the drug related problems; the identified drug related problems were untreated conditions 2 (6.060%) therapeutic duplication 2 (6.060%) dose adjustment in hepatic impairment 1 (3.030%) Sub-therapeutic dosage 2 (6.060%), adverse drug reactions 2 (6.060%), Drug interactions 20 (60.060%), Noncompliance 2 (6.060%) and polypharmacy 3 (9.090%), the drug related problems are summarized in table 2. Table 3 explicate, drug interactions,with severity level, which were detected. The drugs for which more interactions documented were Insulin, diuretics, beta blockers, corticosteroids. Discussion DRPs are relatively common in hospitalized patients and can results in patients morbidity and mortality and increased expenditures [9], the number of drugs used and the number of clinical risk factors considerably and independently influenced the risk for DRPs [10]. A total of 33 drug related problems were identified from 15 patients therapy charts. Most of the DPRs observed in our study resulted from the drug-drug interactions (60.060%), of the total DRPs identified which incorporated more of drug-drug interactions 20, this observation is consistent with the study carried out by Ismail et al [11] in which drug interactions prevalence ranges from 45% to 77.5%, followed by Polypharmacy for three patients more than nine drugs were prescribed. Keeping in view poor economic status of majority population, the health care professional may prescribe minimum possible number of drugs but it is quite understood that large numbers of

3 PhOL Ali et al 106 ( ) drugs may be prescribed in case of need. In Pakistan drug therapy is the most common means of medical intervention. It is specified that average number of drugs prescribed per patient is higher when equated with the rest of the world [12]. A full fledge and established clinical pharmacy system does not exist in the hospital settings of Pakistan [13,14]. Also, irrational use of drugs is common and a serious problem in healthcare setup of Pakistan [12, 15-22]. It is a well-known fact that polypharmacy is strongly associated with DRPs and this has been shown by numerous studies. It has been reported that a one unit increase in the number of drugs can lead to an increase of 8.6% in the number of DRPs [23]. Poly pharmacy carries the risk of drug interactions and adverse drug reactions [24]. In 2 patients conditions were not adequately treated, No relevant drug therapy was prescribed for indication like ascites and ischemic heart disease, which reflects poor health care system that require improvements, 2 followed by therapeutic duplication, 2 sub therapeutic dose, and 1 dose adjustment in hepatic impairment. In this study, Adverse reactions accounted for (6.060%) of the total DPRs. Drug related problems due to patients or provider contributed (6.060%) of the total DRPs which included more of non-compliance. In short drug related problems (DRPs) can interfere with the achievement of desired therapeutic goals. Medication therapy can be rationalized and above problems can be solved by placing pharmacist in the health care providing team in hospital and community level. Pharmacist is the only professional person that can provide information about the dugs both to the health care team and to patients and knowledge about drug related problem. Clinical pharmacy services can be valuable to a health care setting and can potentially lead to a decrease in health care expenses and to an improvement of the standard of patient care. Acknowledgment We gratefully acknowledge the support of Dr, Roheena Zafar, Director Pharmacy services, Northwest General Hospital & Research Centre, Peshawar, Pakistan. Conflict of interest No conflict of interest. References 1. Guyton C. A., Hall, E. J., Insulin, Glucagon and Diabetes Mellitus. In: Textbook Of Medical Physiology. 11th ed., Elsevier saunders. 2006; Blix, H.S., Viktil, K.K., Moger, T.A., Reikvam, A., Drugs with narrow therapeutic index as indicators in the risk management of hospitalised patients. Pharmacy Pract 2010;8(1): Chan, D-C., Chen, J-H., Kuo, H-K., We, C-J., Lu, I-S., Chiu, L-S., et al., Drug-related problems (DRPs) identified from geriatric medication safety review clinics. 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Drug Safety 2000;22(4): Ganachari, M., Mahendra Kumar, B., Shashikala, C.W., Fibin, M., Assessment of drug therapy interventions by clinical pharmacist in a tertiary care hospital. Indian J Pharm Pract 2010;3(3): Ismail, M., Iqbal, Z., Khattak, M.B., Khan, M.I., Arsalan H., Javaid, A. et al., Potential drug-drug interaction in medicine ward in hospital setting in Pakistan. Int J Clin Pharm 2013;35: WHO, The World Medicines Situation nes_situation.pdf. Accessed August 29, Azhar, S., Hassali, M.A., Ibrahim, M.I., Ahmad, M., Masood, I., Shafie, A.A., The role of pharmacists in developing countries: the current scenario in Pakistan. Hum Resour Health 2009;7: Babar, Z.U., Jamshed, S., Social pharmacy strengthening clinical pharmacy: why pharmaceutical policy research is needed inpakistan? Pharm World Sci 2008;30: Ismail, M., Iqbal, Z., Hammad, M., Ahsan, S., Sheikh, A.L., Asim, S.M., Khan, T.M., Drug Utilization Evaluation of Piperacillin/Tazobactam in a Tertiary Care Teaching Hospital. Healthmed 2010;4: Hafeez, A., Kiani, A.G., ud Din, S., Muhammad, W., Butt, K., Shah, Z., MirzaPrescription and dispensing practices in public sector health facilities in Pakistan: survey report. J Pak Med Assoc 2004;54: Imran, M., Khan, F.A., Abbasi, S., Standards for labelling and storage of anesthetic medications--an audit. J Pak Med Assoc 2009;59: Khan, F.A., Hoda, M.Q., Drug related critical incidents. Anesthesia 2005;60: Khowaja, K., Nizar, R., Merchant, R.J., Dias, J., Bustamante- Gavino, I., Malik, A., A systematic approach of tracking and reporting medication errors at a tertiary care university hospital, Karachi, Pakistan. Ther Clin Risk Manag 2008;4: Naeem I, Naqvi BS, Hashmi K, Gauhar S. Paediatric nosocomial infections: resistance pattern of clinical

4 PhOL Ali et al 107 ( ) isolates. Pak J Pharm Sci 2006; 19: Nishtar, S., Pharmaceuticals--strategic considerations in health reforms in Pakistan. J Pak Med Assoc 2006;56: Patel, M.J., Shahid, M., Riaz, M., Kashif, W., Ayaz, S.I., Khan, M.S., Samdani, A.J., Sorathia, A.L., Furqan, M., Drug overdose: a wakeup call! Experience at a tertiary care Centre in Karachi, Pakistan. J Pak Med Assoc 2008;58: Huri, H.Z., Wee, H.F., Drug related problems in type 2 diabetes patients with hypertension: A cross-sectional retrospective study. BMC Endoc Disord 2013;13(1): Ali, N., Shah, S., Khan, J., Rehman, S., Imran, M., Hussian I, et al. Pharmacotherapy-based problems in the management of diabetes mellitus: Needs much more to be done! J Young Pharm 2010;2(3): Table 1. Demographic details of the study patients Characteristics Gender Age group (Years ) Mean Range Average hospital stay Mean Range Diagnoses Diabetes mellitus (Total) Known type II diabetes Gestational diabetes Type I diabetes Numbers (n=15) Male 06 Female 09 Years Days Figure 1. Sign, symptoms and co-morbid Conditions

5 PhOL Ali et al 108 ( ) Table 2. Identified Drug related Problems S.NO Drug related problems Frequency Percentage 01 Untreated conditions % 02 Sub-therapeutic dosage % 03 Adverse drug reactions % 04 Drug interactions % 05 Noncompliance % 06 Dose adjustment in hepatic impairment % 07 Therapeutic duplication % 08 Poly-pharmacy % Table 3. Drug interactions Severity Levels S.No Interaction Frequency Percentage 01 Major Interaction 04 20% 02 Moderate Interaction 13 65% 03 Minor Interaction 03 15%